The Global Network for Tobacco Free Healthcare Services promotes a

concept that integrates all the relevant and key aspects of tobacco

management within healthcare services, in a practical and systematic

approach that is in accordance with the FCTC guidelines

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Membership Agreement and Application Form

ASSOCIATE MEMBER

Associate membership of the Global Network is open to relevant organisations and individual professionals who are willing to endorse, support and promote the implementation of the Global Standards and concept for tobacco management within the healthcare services globally.

This includes:

•public health organizations, academic institutions or NGO’s

•health professionals, academics or other interested experts

By becoming an associate member of the Global Network, you join a global movement to address tobacco use, and partner with healthcare services interested in integrating global developments and international best practice in tobacco control.

To join, please complete the details below and submit the form to the Global Network Coordinating Centre at: . The Coordinating Centre will then confirm your application in writing.

By signing this form, the applicant organisation or individual agrees to abide by the Global Network aims, values and principles. It also agrees to abide by the Code of Conduct and not to receive any funding from tobacco companies or subsidiaries, agents or consultants.

Associate Members remain part of the GNTH if they update their membership details within a minimum 3-years period and share information on any relevant activity with the Coordinating Center.

Membership is valid unless terminated by either party.

Our Vision is to improve population health within healthcare settings by treating tobacco addiction/dependence as part of routine healthcare, denormalising tobacco use, prohibiting use and sale of all tobacco products and associated devices, and eliminating exposure to second-hand smoke and e-cigarette vapor.

Our Mission is tonetwork, and support committed healthcare services and health professionals to implementing tobacco-free policies with the aim of delivering safe quality care for tobacco and nicotine addiction/dependence for every service user, every time and everywhere.

COPYRIGHT POLICY: Global Network materials such as leaflets, brochures, CD’s, etc. whether original or translated are copyright protected by the wording: © “These materials are intended solely for use by health professionals in the implementation of tobacco free policies in healthcare facilities and are not for sale, personal or public use. Members are required to notify and send a copy of all translated materials i.e. Standards, Self-Audit Tool, Certificates and other materials to the Coordinating Centre.

PRIVACY POLICY:The Global Network recognises the importance of privacy protection. Our policy for dealing with any personal and healthcare service information disclosed or received will be treated as strictly confidential. Use of any collected information will only be after advanced information and permission from you and your healthcare services has been obtained.

INDIVIDUAL APPLICANT

Please complete this section if you are applying as an individual for Associate Membership.

Joining Year
Country
Region/State
Role in relation to tobacco management / control / Please describe in one brief statement your interest or role with respect to tobacco management / control
Applicant [Full] / Title:
Name:
Job Title/Position:
Organisation (if relevant):
Contact details for correspondence / Postal Address:
E-mail:
Website (if applicable)
This application, signed by the individual seeking membership, is anagreementof commitment by the applicant to endorse and promote the implementation of a tobacco free policy and activities in accordance with the GNTH Code of Conduct, Standards and concept for tobacco management within healthcare services globally and agrees not to receive any funding from tobacco companies or subsidiaries, agents or consultants.
Signature:
Date:

ORGANISATION APPLICANT

Please complete this section if you are applying as an organisation for Associate Membership.

Joining Year
Country
Region/State
Name Organisation [ENGLISH]
Name Organisation [LOCAL LANGUAGE]
Role in relation to tobacco management / control / Please describe in one brief statement your organisation’s role or interest with respect to tobacco management / control
Type of Organisation
Organisation
Postal Address
Website
Contact person for correspondence / Title:
Name:
Job Title/Position:
Organisation:
E-mail:
This application, signed by the highest officer of the organisation seeking membership, is anagreementof commitment by the applicant to endorse and promote the implementation of a tobacco free policy and activities in accordance with the GNTH Code of Conduct, Standards and concept for tobacco management within healthcare services globally and agrees not to receive any funding from tobacco companies or subsidiaries, agents or consultants.
Senior Manager contact details / Title:
Name:
Position:
Organisation:
E-mail:
Signature:
Date: